Megan Whitley June Case Study July 2, 2013 Electronic Compensation for Radiotherapy of the Right Breast History

of present illness: JG is a 71 year old female who was recently diagnosed with Infiltrating Ductal Carcinoma of the right breast. This breast cancer was diagnosed after abnormal findings were established during a routine mammogram. JG then underwent a diagnostic ultrasound verifying the presence of a 2.2 centimeter (cm) mass with a 2 cm spiculated extension. JG also had chest wall involvement determined to be a 1 cm invasion. In mid-March JG had an ultrasound guided core biopsy revealing IDC Grade 1, estrogen receptor positive. Twelve days later a magnetic resonance imaging (MRI) scan revealed and irregular mass in JGs lateral posterior breast continuing to the adjacent pectoralis muscle with neovascularization. An anterior abnormality extending from the main mass, including 2 nodes, with 2 additional nonspecific foci was also seen. JG underwent a lumpectomy and sentinel lymph node biopsy at the beginning of April. The pathology from the lumpectomy revealed T1(stage 1 tumor), N0 (no lymph node involvement), IDC Estrogen Receptor (ER) 5-10% + Progesterone Receptor (PR) negative, Human Epidermal Growth Factor 2 (HER 2) tumor with a posterior margin of 2 millimeters (mm). The T1 indicates a small tumor size, one less than or equal to 2 cm in its greatest dimension.1 ER stands for estrogen receptor, and when it is positive, like it is in JGs case, its very influential for the treatment purposes. ERs are overexpressed in about 70% of breast cancer cases, labeling them as ER positive cases.2 There are 2 different hypotheses on why ER is so impactful on tumor growth. The first hypothesis is that the estrogen itself associated with ERs, stimulates the proliferation of mammary cells, which increases cell division, thus increasing the proliferation of mutated cells.2 The other hypothesis is that estrogen metabolism produces genotoxic waste, which is carcinogenic.2 In either case, the involvement of ERs in a tumor cause a higher potential for tumor growth and/or dangerous cell mutation. Past Medical History: JG has a history of hypothyroidism, anxiety, hypertension, allergic rhinitis, cholelithiasis, pancreatic duct stricture, carpal tunnel neuropathy in both hands and spinal stenosis with associated back pain since 1997. She has a surgical history of cataract
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removal, tonsillectomy, Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy, and a broken left wrist requiring Open Reduction Internal Fixation (ORIF). More recently shes added a right breast core biopsy and right breast partial mastectomy to her growing list of surgeries. Social History: JG is married with 2 children and she has never been a smoker. She is an ovolacto vegetarian. The patient does not have cancer in the family. Medications: JG is on several medications including B complex vitamin, Centrum Silver 1 tablet daily, Diphenhydramine 25 milligrams (mg) every 6 hours as needed, Levoxthyroxine 150 micrograms (mcg) daily, Lisinopril 1 tablet daily, and Propanolol 10 mg twice daily. She has allergies to both latex and codeine sulfate. Radiation Oncologists Recommendations: Due to the diagnosis and location of the patients surgical cavity, the radiation oncologist (RO) recommended JG for a protocol, RTOG 1005. Unfortunately the time from surgery to beginning treatment had been too long and extended past the window set in the protocol. Hence, the recommendations were changed to the standard treatment regimen preferred by this RO, hypofractionated radiation therapy with a boost. The Plan (the prescription): The RO prescribed 4256 centigray (cGy) to be administered in 266cGy doses, over 16 fractions. The RO communicated to dosimetry several key points: mixed beam energies could be used if needed, electronic compensators were preferred, and weighting higher than 30% on the 18 Megavoltage (MV) required verification. The patient denied chemotherapy. Patient Setup/Immobilization: In the simulator the patient was informed of the procedure. The process was explained in terms she could understand, in hopes of soothing any anxiety she had about the simulation for treatment planning. Before the patient was placed on the table, a wingboard was attached to the table (Figure 1). The wingboard and headrest were used for stability and a Vac-Lok was placed within that stable framework (Figure 2). JG was placed on the table, resting on the Vac-Lok with her arms above her head with a knee wedge beneath her knees for added comfort. Both arms were raised above the head due to a presumed increase in position reproducibility. The air was then removed from the Vac-Lok, which contoured and captured her placement at the time of simulation. For planning purposes, fiducial markers and radiopaque markers were used to outline breast tissue on the inferior, superior, medial, and lateral aspects, and delineate her nipple and lumpectomy scar. After the scan was completed on
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the GE LightSpeed, marks were drawn on her skin, depicting the regions of interest established and confirmed by the scan. Pictures were taken to record the patient setup for reproducibility at the time of treatment. Anatomical Contouring: After the patients scan was transferred to Eclipse for planning, contouring was done of both the lungs separately, and then a structure combining them, as well as the heart, the body, scar, and field delineating wires, spinal cord, liver, and thyroid gland. As seen in Figure 3, the entire breast tissue had been defined by a wire, circling the breast. The radiation oncologist contoured the gross tumor volume (GTV), which is the cavity, or balloon, to designate the extent of the tumor cavity. After the GTV was constructed, an expansion structure was generated using an auto margin function within Eclipse. A 1 cm expansion was placed on the GTV and labeled PTV or cavity + 1. Typically the plans coverage is primarily evaluated in terms of the GTV, but the PTV is of concern to confirm that any remnant microscopic disease be irradiated. Beam Isocenter/Arrangement: The RO set both the isocenter and the medial field at the time of simulation, but altered the field once the treatment volumes were contoured. These treatment volumes allowed the dosimetrist and RO to gauge what strategies would be required for effective treatment. When deciding beam arrangements, energies, and calculation point placement, the depth and location of the cavity are of utmost importance. These determine how difficult or easy it will be to fully and accurately obtain proper radiation coverage. Treatment Planning: To plan JGs treatment, a tangential approach was used. Due to the placement of the cavity or GTV, mixed energies were chosen. Deep penetration towards the chest wall was required to fully cover the GTV and PTV as seen in Figure 4. This was fulfilled by duplicating the tangents and changing the additional beams energies from 6 MV to 18MV. There were a total of 4 beams for the plan. Changing the weighting between the fields was also important because it allowed the dosimetrist to obtain needed penetration, increasing the chest wall dosage. The final weighting for the plan was 60% of the dose by the 6MV fields and 40% of the dose by 18MV fields. Since the weighting on the 18 MV beams totaled greater than 30%, the weighting was verified by the RO. The last measure taken to increase the depth of the dose was to place the calculation point posteriorly to the central axis, as shown in the axial view in Figure 5, and in the sagittal view in Figure 6. After a location for the calculation point is determined, the point must be assigned to the prescription in order to deliver 100% of the dose to
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this point. Not prescribing to the posterior calculation point would result in the entirety of dose to the isocenter. It is important to verify that the point has been assigned; checking to make sure that the dose is focused at the correct point, and increases the coverage to the area of concern. Electronic compensators (ECs) were used to decrease the hot spot in the plan while maintaining optimal coverage. ECs provide the effect of both a block and a wedge. When the irregular surface compensators, or ECs, are initially added to a field, a determination must be set for the wedge degree (Figure 7). It is typical to begin with 30 degrees on each EC and alter it as needed. Also, the ECs are only placed on beams using 6MV energy. The reason for this is the fear of neutron contamination within the field if used with higher energies. The neutron contamination would come from the radiation interaction between the MLC leaves. Once the ECs are allotted and an initial calculation is done, the skin flash of 2.0 cm is drawn, the areas of changing transmission are smoothed, the transmission in the skin flash region is assigned to 0.6, and the fluence is altered. This alteration of fluence orchestrates how the multi-leaf collimators (MLCs) move, which develops a healthy coverage of dose, while decreasing the region of excess dose. The overall hot spot for this plan at completion was 106.5%. The RO was very pleased with this and decided to prescribe to the 99% line to increase the coverage. This inherently increased the hot spot to about 107.5%. This was still an acceptable range, and the RO signed off on the plan for achieving all of the goals set for dosimetry. The dose volume histogram represents the doses received by the organs at risk and the treatment volumes (Figure 8). Quality Assurance/Physics Check: After the plan was approved by the RO, a second check was done in RadCalc to verify the calculations. All 4 of the beams in the second check require a differentiation of less that 2% to pass. JGs plan passed the second check (Figure 9). At the facility, when ECs are used, physics has to perform a quality assurance (QA) test to verify the accuracy of the plan. Once the plan was approved and ready for treatment, the final step was to generate and perform a trial fraction, making sure that the information accurately transferred to the record and verify software, and that the plan would behave in the manner in which it was intended. The trial fraction was done on the treatment machiner, a Varian Trilogy IX, and verified by the physics quality assurance tool, a Delta4 phantom. The fluence that registered within the Delta4 was compared to the approved treatment plan fluence. The Delta4 functions from a gamma analysis. The absolute dose evaluation and gamma analysis of the fluence were performed and compared to the measured dose delivered against the calculated phantom plan.
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For the plan to pass QA, 95% of all the points tested within the phantom must have a 3% deviation from the predetermined dose. This plan passed QA. Conclusion: This patient held many lessons within the planning. The predominant amount of training was gained by watching different tactics influence the dose coverage. The outcome was also surprising, determining that it was not a choice of one tactic over another, but the use of many strategies that created the optimal plan. The use of mixed energies illustrated the depth differences at which an 18MV beam energy versus a 6MV beam. By placing, moving, and reassigning the calculation point, the impact these strategies provided became apparent. Then the ECs were added to the plan achieving conformal dose distribution, decreasing the hot spot, and providing the most practical and reproducible plan. Due to a lack of knowledge on the effect of estrogen receptors, the role ERs take in the determination for the treatment for breast cancer was addressed. The information as to why ERs are important and impactful can be found within this case study and utilized to enhance patient outcomes in the future.

Figures

Figure 1. Pictured is a wingboard treatment device with a headrest used for daily treatment setup.

Figure 2. This is a Vak-Lok placed on top of the wingboard and headrest, which will be shaped to the patient to establish immobilization.

Figure 3. This is a multiplanar view of the patient with her contours turned on.

Figure 4. The GTV (blue) and the PTV (red) can be seen. Due to the deep location of the treatment volume, use of 18 megavoltage energy was required.

Figure 5. The red crosshair represents the placement of the calculation point.

Figure 6. This is a sagittal view of the calculation point, located at the crosshair, labeled Right Breast.

Figure 7. This shows the medial 6MV field with the EC.
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Figure 8. This is the DVH which represents the dose to each structure of concern within the plan.

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Figure 9. This is the RadCalc, performed to second check the calculations done in Eclipse. In the Percent Diff blank, the percentage of difference between the calculations is represented, and must be below 2% to pass. These, as shown, are all below 2%, thus passing.

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References 1. Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:348. 2. Wikipedia. Estrogen Receptor. Last modified June 28, 2013. http://en.wikipedia.org/wiki/Estrogen_receptor. Accessed July 5, 2013. 3. U.S. Department of Health and Human Services website. (ERCP) Endoscopic Retrograde Cholangiopancreatography. Last modified June 29, 2012. http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/. Accessed July 5, 2013.

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